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Inpatient CPT question

  1. Default Inpatient CPT question
    Medical Coding Books
    Can you code for inpatient day if you do not do a physical exam on that day? Example: Notified by nursery baby born to your service and you give orders for newborn but don't do the physical exam until the next day. Do you bill on day of life 1 for initial or day of life 2?

  2. #2
    Duluth, Minnesota
    I'm dumbfounded.... I thought all babies born had an exam pretty much immediately upon birth... ??... I mean, they aren't just born, then left to be checked another day. At minimum the APGAR is done, which of course would then indicate (usually) whether or not a more "complete" exam was needed.

    or am I way off base here?....
    Donna, CPC, CPC-H

  3. #3
    Milwaukee WI
    Default BIll for date of service
    You'd bill for the date of service when the care was provided. If it's day of life 2 that's the date you bill the admit. (This can easily happen if child is born close to midnight, but not seen until after midnight.)

    F Tessa Bartels, CPC, CPC-E/M

  4. Default
    Not all pediatricians attend the deliveries. My group is a hospitalist group that attends all c-sections and vaginal deliveries when there is a problem. If there is no pediatrician at the delivery the nursery nurse assigns the apgars. I have an outside pediatrician group telling me they bill for day of life 1 even if they do not see the baby until the next day (this happens when the baby is born in the evening hours) and I am telling them they shouldn't without examing the baby and writing a note on the chart. Just wanted to make sure I was advising them correctly.
    Thank you.

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